Nursing Elites

1. The client had surgery one day ago. What assessment is most likely related to pain?

• A. Blood pressure of 175/90 mm Hg
• B. Respirations of 10 breaths per minute
• C. Heart rate 60 beats/minute
• D. Oxygen saturation of 97%

Correct answer: A

Rationale:

2. Which organization publishes the National Patient Safety Goals?

• A. The Joint Commission
• B. Medicare
• C. The American Nurses Association
• D. The Institute of Medicine

Correct answer: A

Rationale:

3. A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?

• A. Avoid exercise during flare-ups
• B. Do high impact exercises like running
• C. Establish a regular sleep pattern
• D. Increase calcium and caffeine intake

Correct answer: C

Rationale:

4. Which practice is recommended to prevent human immune deficiency virus (HIV) transmission by health care workers?

• A. Wearing a mask within three feet of the client
• B. Intentional
• C. Using standard precautions
• D. Proliferative

Correct answer: C

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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